CHEST PAIN
Dr.Redha 2013Chest pain is a frequent manifestation of both cardiac and respiratory disease.Pleural or chest wall involvement by lung disease gives rise to sharp, peripheral pain which is exacerbated by deep breathing or coughing (Box below).Central chest pain suggests heart disease but also occurs with tumours affecting the mediastinum, oesophageal disease or disease of the thoracic aorta.Massive pulmonary embolus may cause ischaemic cardiac pain as well as severe breathlessness. Tracheitis produces raw upper retrosternal pain, exacerbated by the accompanying cough. Musculoskeletal chest wall pain is usually exacerbated by movement and associated with local tenderness.
Differential diagnosis of chest pain
Central
Cardiac
Myocardial ischaemia (angina)
Myocardial infarction
Myocarditis
Pericarditis
Mitral valve prolapse syndrome
Aortic
Aortic dissection
Aortic aneurysm
Oesophageal
Oesophagitis
Oesophageal spasm
Mallory-Weiss syndrome
Massive pulmonary embolus
Mediastinal
Tracheitis
Malignancy
Anxiety/emotion
Peripheral
Lungs/pleura
Pulmonary infarct
Pneumonia
Pneumothorax
Malignancy
Tuberculosis
Connective tissue disorders
Musculoskeletal
Osteoarthritis
Rib fracture/injury
Costochondritis (Tietze's syndrome)
Intercostal muscle injury
Epidemic myalgia (Bornholm disease)
Neurological
Prolapsed intervertebral disc
Herpes zoster
Thoracic outlet syndrome
HAEMOPTYSIS
Coughing up blood, irrespective of the amount, is an alarming symptom and patients nearly always seek medical advice. A history should be taken to establish that it is true haemoptysis and not haematemesis, or gum or nose bleeding. Haemoptysis must always be assumed to have a serious cause until this is excluded (Box).
Many episodes of haemoptysis remain unexplained even after full investigation, and are likely to be caused by simple bronchial infection. A history of repeated small haemoptysis, or blood-streaking of sputum, is highly suggestive of bronchial carcinoma. Fever, night sweats and weight loss suggest tuberculosis.Pneumococcal pneumonia often causes 'rusty'-coloured sputum but can cause frank haemoptysis, as can all suppurative pneumonic infections including lung abscess .
Bronchiectasis and intracavitary mycetoma can cause catastrophic bronchial haemorrhage, and in these patients there may be a history of previous tuberculosis or pneumonia in early life. Finally, pulmonary thromboembolism is a common cause of haemoptysis and should always be considered. Physical examination may reveal additional clues. Finger clubbing suggests bronchial carcinoma or bronchiectasis; other signs of malignancy, such as cachexia, hepatomegaly and lymphadenopathy, should also be sought. Fever, pleural rub or signs of consolidation occur in pneumonia or pulmonary infarction; a minority of patients with pulmonary infarction also have unilateral leg swelling or pain suggestive of deep venous thrombosis.
Rashes, haematuria and digital infarcts suggest an underlying systemic disease such as a vasculitis, which may be associated with haemoptysis.
Causes of haemoptysis
Bronchial disease
Carcinoma*
Bronchiectasis*
Acute bronchitis*
Bronchial adenoma
Foreign body
Parenchymal disease
Tuberculosis*
Suppurative pneumonia
Lung abscess
Parasites (e.g. hydatid disease, flukes)
Trauma
Actinomycosis
Mycetoma
Lung vascular disease
Pulmonary infarction*
Goodpasture's syndrome
Polyarteritis nodosa
Idiopathic pulmonary haemosiderosis
Cardiovascular disease
Acute left ventricular failure*
Mitral stenosis
Aortic aneurysm
Blood disorders
Leukaemia
Haemophilia
Anticoagulants
Management
In severe acute haemoptysis, the patient should be nursed upright (or on the side of the bleeding if this is known), and given high-flow oxygen and appropriate haemodynamic resuscitation.
Bronchoscopy in the acute phase is difficult and often merely shows blood throughout the bronchial tree.
If radiology shows an obvious central cause, then rigid bronchoscopy under general anaesthesia may allow intervention to stop bleeding; however, the source often cannot be visualized.
Intubation with a divided endotracheal tube may allow protected ventilation of the unaffected lung to stabilize the patient.
Bronchial arteriography and embolization , or even emergency pulmonary surgery, can be life-saving in the acute situation.
Investigations
In the vast majority of cases, however, the haemoptysis itself is not life-threatening and a logical sequence of investigations should be followed:
• Chest X-ray, which may give evidence of a localized lesion including pulmonary infarction, tumour (malignant or benign), pneumonia, mycetoma or tuberculosis
• Full blood count and clotting screen
• Bronchoscopy after acute bleeding has settled, which may reveal a central bronchial carcinoma (not visible on the chest X-ray) and permit biopsy and tissue diagnosis
• CTPA, which may reveal underlying pulmonary thromboembolic disease or alternative causes of haemoptysis not seen on the chest X-ray (e.g. pulmonary arteriovenous malformation or small or hidden tumours).
CYANOSIS
Is an abnormal bluish discoloration of the skin resulting from an increase in the level of reduced hemoglobin in the blood. In general, reflects an arterial oxygen saturation of 85% or less (normal arterial oxygen saturation, ≥ 95%).
Central cyanosis:
Exhibits as cyanosis of the lips or trunk and often reflects right-to-left shunting of blood caused by:
1- Structural cardiac abnormalities e.g.
Atrial or
Ventricular septal defects)
2- Pulmonary parenchymal or vascular disease e.g.
Chronic obstructive pulmonary disease,
Pulmonary embolism,
Pulmonary arteriovenous fistula).
Peripheral cyanosis :
May occur because of systemic vasoconstriction in the setting of poor cardiac output or may be a localized phenomenon resulting from venous or arterial occlusive or vasospastic disease e.g.
Venous or arterial thrombosis.
Arterial embolic disease.
Raynaud disease.
When cyanosis occurs in childhood, it usually reflects congenital heart disease with right-to-left shunting of blood
INCIDENTAL PULMONARY NODULE ON IMAGING
A pulmonary nodule may be defined as a round opacity which is at least moderately well marginated and no greater than 3 cm in diameter.The majority are benign; however, the differential diagnosis is extensive (Box) and includes early malignant disease that may be treatable.
Causes of pulmonary nodules
Common causes
Bronchial carcinoma
Single metastasis
Localized pneumonia
Lung abscess
Tuberculoma
Pulmonary infarct
Uncommon causes
Benign tumours
Lymphoma
Arteriovenous malformation
Hydatid cyst .
Bronchogenic cyst
Rheumatoid nodule
Pulmonary sequestration
Pulmonary haematoma
Wegener's granuloma
'Pseudotumour'-fluid collection in a fissure
Aspergilloma (usually surrounded by air 'halo')
Clinical and radiographic features distinguishing benign from malignant nodules*
Risk status of patient
Age:Increasing age increases likelihood of malignancy. Lung cancer is uncommon under the age of 40 and
rare under 35
Smoking history: Risk of malignancy increases in proportion to duration and amount smoked
History of malignancy : Risk of malignancy increased by history of lung cancer in a first-degree relative, and by exposure to asbestos, silica, uranium and radon
Characteristics of nodule
Size: Greater probability of malignancy with increasing size. Nearly all nodules > 3cm are malignant; less than 1% of very small (< 4 mm) nodules are malignant, even in smokers; 10-20% in the 8 mm range will prove cancerous
Margin: Usually smooth in benign lesions; malignant lesions have a spiculated margin
Density: Most cancerous lesions are solid, but most solid lesions are non-cancerous. A partly solid lesion or one with air lucencies is more likely to be malignant than a solid lesion. Ground glass lesions with malignant potential grow very slowly and require longer follow-up
Calcification or fat: These favours benign disease, although CT may detect calcification in some malignant lesions. A laminated or central deposition of calcification is typical of a granuloma, while a 'popcorn' pattern is suggestive of a hamartoma. Fat content is consistent with a hamartoma or a lipoid granuloma.
Location:70% of lung cancers occur in the upper lobes and the right lung is more commonly affected than the left lung. Benign lesions are equally distributed throughout upper and lower lobes.
Contrast enhancement: Lack of contrast enhancement (< 15 HU) has a high negative predictive value for malignancy, but is non-specific with a poor positive predictive value. Not useful in lesions < 8 mm in diameter.
Lymphadenopathy: Hilar or mediastinal adenopathy favours a malignant process and is important for staging
Recommendations for follow-up of incidental nodules smaller than 8 mm1
Nodule size (mm) Low-risk patient High-risk patient
≤ 4 No follow-up needed Follow-up CT at 12 months; if
unchanged, no further follow-up
4-6 Follow-up at 12 months; if unchanged, no further follow-up Initial follow-up CT at 6-12
months, then at 18-24 months if
no change
6-8 Initial follow-up CT at 6-12 months then at 18-24 months if no change Initial follow-up CT at 3-6 months,
then at 9-12 months if no change
> 8 Follow-up CT at around 3, 9 and 24 months, dynamic contrast-enhanced CT, PET and/or biopsy As for low- risk
patient
PLEURAL EFFUSION
Pleural effusion :The accumulation of serous fluid within the pleural space .
Empyema :The accumulation of frank pus within the pleural space.Haemothorax : The accumulation of blood within the pleural space .
Chylothorax :The accumulation of chyle within the pleural space.
Transudative effusion'pleural fluid accumulates as a result of either increased hydrostatic pressure or decreased osmotic pressure, as seen in cardiac, liver or renal failure), or
Exudative effusion': from increased microvascular pressure due to disease of the pleural surface itself or injury in the adjacent lung
END